Diciccio, James G ` NEW-'ORK STATE DEPARTMENT OFHEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
James G. DiCiccio Sr. male
Date of... eath::::............................................... .....................................................
»:
Age ff Veteran of U.S."A'rmed Forces,
7/19/1990 40 War or Dates no
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Z Place of Death :: Hospital, Institution or
City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
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� Cause of Death ....................................................................................................
upshot wound to chest
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ffj; Medical Certifier Name Title
0...............:::::::::::::::::.........:::::::::.. .:::R .::::S itzer:,:::::::::;:::::::::::::::::::::.::.:..:::.:::::.:..MD.........................................................................................
Address ...........................................-,....................................................:::::::::::::::......::::.
::..::::,,::::::.::::::.:::.::::::::.:::::::::::::::::..:Box 139,....Glens...Falls:....New...York...12801
Death Certificate Filed District Number : Register Number
<< City,Town or Village City of Glens FAlls
Date Cemetery or Crematory
❑Burial
7/23/1990.::::::.:.::.::::::::::.::::::.::_:::;:::::::::::Pine,::View:::Crematory:::::::::::::.::::.............:.::. .....................................
...
®Cremation Address
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Z!I Date Place Removed
Q El Removal and/or Held
1- ...and/or Hold:: .......................................................................................................................
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Address _ _.........
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t Date Point of
N; ❑Transportation by'. Shipment
Common Carrier ...................................................................................................................................................
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Destination
❑ Disinterment Date Cemetery Address
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❑ Reinterment Date Cemetery Address
Permit Issued to i Registration Number
Name of Funeral Firm Regan and Denny Funeral Service Inc. 01634
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Address
26 Quaker Road, Queensbury, New York 12804
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Address
A
Permission Is hereby granted to dispose of the human remains described above as Indicated.
Date Issued C_ Registrar of Vital Statistics 9VL,� d
�// a (signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition "oZoZ -9O Place of Disposition ,/7/
(address)
w
(section) Y (lot number) (grave number)
p! Name of Sexton Person i Charge of Pre ises E& k"f Ajd Z 4/
Wi Signature (please print)Title /f G10� SS
DOH-1555(9/86)p 1 of 2(formerly VS-61)